Childcare Disqualification Requirements: Employee and Volunteer Declaration Form

School Name

Please refer to the accompanying letter for detailed information about the requirement for you to make this declaration.

In accordance with the legislation you are asked to sign the declaration below confirming that you are not disqualified from working in, or being concerned in the management of, the above settings.

If you fail to complete and return the form, this will be regarded as a disciplinary matter for staff, which may result in dismissal, and, in the case of volunteers, will mean that you can no longer work at this establishment.

A disqualified person is not permitted to continue to work in the above settings unless they apply for and are granted a waiver from

Name of person signing the declaration

First

Last

Post Held

Have any orders or other determinations related to childcare been made in respect of you?

Have any orders or other determinations related to childcare been made in respect of a child in your care?

Have any orders or other determinations been made which prevents you from being registered in relation to childcare, children's homes or fostering?

Are there any other relevant orders, restrictions or prohibtions in respect of you as set out in Scedule 1 of the Regulations? Available at the link: http://www.legislation.gov.uk/uksi/2018/794/schedule/1/made

Are you barred from working with children (disclosure and barring (DBS))?

Section 2 - Specified and statutory offences

Have you ever been cautioned, reprimanded, given a warning for, or convicted of:

Any offence against or involving a child? (A child is a person under the age of 18)?

Any violent or sexual offence against an adult?

Any offence under the Sexual Offences Act?

Any other relvant offence?

Have you ever been cautioned, reprimanded, given a warning for or convicted of any simular offence in another country?

Section 3 - Provision of Information

If you have answered YES to any of the questions above you should provide details below in respect of yourself. You may supply this information separately if you so wish, but you must do so without any delay.

Details of the other, restriction, conviction or other grounds for disqualifications

Date(s) of these:

The relevant court(s) or body(ies) and the sentence (if any) imposed

You shouold also provide a copy of the relevant order, caution etc. In relation to cautions/convictions a DBS certificate may be provided

Section 4 - Declaration

In signing this form, I confirm that the information provided is true to the best of my knowledge and that

I understand my responsibilties to safeguard children
I understand that, I muts notify my head teacher immediately of anything that affects my suitability including any cautions, warnings, convictions, orders or other determinations that would render me disqualified from working with children

Signature

Name

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Date